Palmetto Surety Corporation Agent Application

Palmetto Surety Corporation Agent Application
Application Type*
Application State*
Agency Name*
Please enter the name of your agency or the name of the agency you are applying to work with
Agency License Number
Please enter the license number for your agency as issued by your states licensing authority
Agency Owner Name*
Please enter your name or the name of the agency owner you are applying to work with
PSC Agency Number (if available)
Please enter the PSC agency number for the agency you are applying to work with (if available)
Agency Phone Number*
Please enter your agency phone number, or the phone number for the agency you are applying to work withFormat: (000) 000-0000.
Agency Email*
Please enter your email address, or the email address for the agency you are applying to work with
Agency Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Agency Mailing Address (If Different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Duration of Ownership
Tax ID (EIN)
If you are an LLC or Inc. please enter your EIN
Sales Representative (if any)
Do you currently work in the Bail Bond Profession?
How long have you worked in the Bail Bond Profession?
Please list your current surety company/companies below.
MGA Information
MGA Agency Name
MGA Owner Name*

First NameLast Name
MGA Owner Email
example@example.com
MGA Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
MGA Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Personal Information
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security No.*
Driver’s License No.*
DL Issue Date*

MonthDayYear
Date
DL Expiration Date*

MonthDayYear
Date
Agent License Number*
Please enter the state Department of Insurance issued individual Bail Bondsman license number for the applicant. If the applicant does not have a license number please enter N/A
Home County of Residence*
Phone No.*
Format: (000) 000-0000.
Email Address*
example@example.com
Applicant Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Significant Other’s Name
What type(s) of insurance license(s) do you currently hold?
General Power of Attorney Information

Please enter the counties or parishes for which you will need a Qualifying Power of Attorney to Register your license
Please list all of the counties for which you will need a General Power of Attorney Form:
Company/Employer Information
Current Employer Name*
Current Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone No.
Format: (000) 000-0000.
Duration of Employment
May this employer be contacted?
Employment History (Last 5 Years)
Name of Employer
Period of Employment
Education Information
High School
City/State
Degree
Years Attended
College/Trade School
City/State
Degree
Years Attended
Other Training
References
Name
Years Known
Reference Phone No
Format: (000) 000-0000.
Name
Years Known
Reference Phone No.
Format: (000) 000-0000.
To Make the transition to Palmetto Surety Corporation as simple as possible, the following information is needed:
Face Value Volume Written Annually
Face Value Volume you anticipate to write with Palmetto Surety Corporation
Total Number of Estreatments
Number of Bonds Written Annually
Do you currently have a Build Up Fund with a prior Insurance Carrier?
How much is in the account?
Please list any other assets that may be used as collateral, including cash, property and other holding accounts:
Financial Statement
Assets:
Cash
Home Mortgage
Stocks/Bonds
Other Mortgages
401k/IRA
Payables
Receivables
Other Real Estate
Other Assets
Other Debt
Total Assets
Total Liabilities
I hereby affirm, under penalty of perjury, that the foregoing declarations made and answers given are the truth without reservation. I authorize you to verify the information on this application and to receive and exchange information about me, including requesting reports from consumer reporting agencies, criminal reports, driving records and any other relevant source. I authorize Palmetto Surety Corporation to submit any information from this application to the South Carolina Department of Insurance or any business partner of the NIPR for licensing or information change purposes. If my application is approved, I authorize you to contact these sources for information at any time, to use information about me, including information from this application and from consumer reports.
Applicant Signature*

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Date Submitted*

MonthDayYear
Date
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Palmetto Surety Corporation Agent Application

MGA Information

Personal Information

General Power of Attorney Information

Company/Employer Information

Education Information

References

Financial Statement

Assets: